Fibroids and Endometriosis After Complete Hysterectomy Symptoms: Why It Happens and What Helps

It can be confusing and frustrating to have pelvic pain, pressure, or new bleeding after a “complete” hysterectomy. If the uterus is gone, how can fibroids or endometriosis still cause symptoms? The short answer: while uterine fibroids themselves cannot regrow without a uterus, fibroid-like growths can appear elsewhere in rare situations, and endometriosis can persist or recur because it often lives outside the uterus. Understanding why this happens and what treatments help can bring clarity—and relief.

First, what does “complete hysterectomy” mean?

Terms matter. A total (sometimes called “complete”) hysterectomy removes the uterus and cervix. If the ovaries and fallopian tubes are also removed, it’s called bilateral salpingo-oophorectomy (BSO). Many people say “complete” to mean the uterus, cervix, and both ovaries were removed; others mean just the uterus and cervix. Your risk of ongoing hormone-driven symptoms (like endometriosis pain) is higher if one or both ovaries remain.

Can fibroids or endometriosis happen after hysterectomy?

Fibroids

Uterine fibroids (leiomyomas) are benign muscle tumors of the uterus. If the whole uterus is removed, those specific fibroids cannot grow back. However, rare scenarios can cause fibroid-like growths or masses after hysterectomy:

• Cervical stump fibroids: If the cervix was left in place (supracervical hysterectomy), fibroids can develop in the remaining cervical tissue.
• Parasitic leiomyomas: Small pieces of fibroid tissue can reimplant in the abdomen or pelvis, especially after prior morcellation (a technique that fragments tissue). These “parasitic” fibroids can grow under estrogen influence.
• Disseminated peritoneal leiomyomatosis: Very rare benign smooth muscle nodules scattered in the abdomen.

Because power morcellation can spread both benign and, in rare cases, unsuspected cancerous tissue, the U.S. Food and Drug Administration (FDA) issued safety communications recommending careful patient selection and the use of containment systems when morcellation is appropriate.

Endometriosis

Endometriosis occurs when tissue similar to the uterine lining grows outside the uterus (on the ovaries, bowel, bladder, pelvic lining, and more). Removing the uterus doesn’t remove those outside implants. If the ovaries remain, estrogen can continue to stimulate the implants; even after ovary removal, residual implants can persist, and rare extra-ovarian estrogen production can sustain them. That’s why some people still have endometriosis symptoms after hysterectomy.

Why symptoms can persist or appear after hysterectomy

• Residual or recurrent endometriosis: Microscopic implants left behind can continue to cause inflammation and pain.
• Ovarian remnant syndrome: If ovaries were intended to be removed but a small fragment remains, it may continue producing hormones and cause cyclic pain or a pelvic mass.
• Hormone therapy effects: Estrogen therapy after hysterectomy can relieve menopausal symptoms, but in patients with a history of endometriosis, it may reactivate residual disease; adding a progestin is sometimes considered.
• Adhesions and pelvic floor dysfunction: Scar tissue and muscle spasm can mimic or amplify pelvic pain.
• Vaginal cuff or cervical stump issues: Granulation tissue at the vaginal cuff (the internal incision) can cause spotting; if the cervix remains, the residual tissue can bleed.
• Other conditions: Interstitial cystitis/bladder pain syndrome, irritable bowel syndrome, hernias, or neuropathic pain can present similarly.

Common symptoms to watch for

• Pelvic or lower back pain (cyclic or constant)
• New abdominal or pelvic mass or pressure
• Bloating, constipation, or painful bowel movements
• Urinary urgency or frequency
• Pain with sex
• Vaginal spotting or bleeding (particularly if the cervix remains or from vaginal cuff granulation tissue)
• Hot flashes, night sweats, or mood changes (if ovaries were removed)

How clinicians evaluate symptoms after hysterectomy

• History and exam: Details about the original surgery (was the cervix or ovary removed?), timing of symptoms, cyclic patterns, and medication/hormone use.
• Imaging: Pelvic ultrasound (transvaginal if the cervix remains, transabdominal otherwise) to look for masses; MRI for complex cases or suspected deep endometriosis.
• Laboratory tests: Targeted tests when indicated; tumor markers like CA-125 are nonspecific.
• Diagnostic laparoscopy: Minimally invasive surgery to confirm and treat endometriosis, remove residual ovarian tissue, or excise parasitic fibroids.
• Pathology: Tissue analysis if a mass is removed, to rule out rare malignancy.

What helps: evidence-based options

Medication and hormone strategies

• NSAIDs for pain and inflammation.
• Hormonal suppression for endometriosis (if ovaries remain): options include continuous combined hormonal therapy, progestin-only therapy (norethindrone acetate, depot medroxyprogesterone). A levonorgestrel IUD is not applicable if the uterus was removed.
• GnRH agonists or antagonists: Medicines that lower estrogen to quiet endometriosis activity. FDA-approved oral GnRH antagonists include elagolix for moderate-to-severe endometriosis pain and relugolix combination therapy (with estradiol and norethindrone) approved for endometriosis-associated pain and for fibroid-related bleeding (the latter not relevant post-hysterectomy). “Add-back” low-dose hormones reduce side effects like bone loss.
• Aromatase inhibitors (off-label in endometriosis): In select refractory cases, often combined with other agents and specialist oversight.
• Hormone therapy after BSO: If you need estrogen for menopausal symptoms and have a history of endometriosis, discuss risks and consider adding a progestin; careful monitoring is prudent.

Procedures and surgery

• Excision of endometriosis: Laparoscopic removal of implants and adhesions can relieve pain and improve function.
• Removal of residual ovarian tissue (for ovarian remnant syndrome): Precise surgical excision guided by imaging.
• Excision of parasitic leiomyomas or cervical stump fibroids: Surgical removal and confirmation by pathology.
• Treatment of vaginal cuff granulation: In-office application of silver nitrate or minor excision to stop spotting.

Supportive care and lifestyle

• Pelvic floor physical therapy for muscle spasm and dyspareunia.
• Neuromodulators (e.g., low-dose tricyclics, SNRIs, gabapentinoids) for neuropathic pain, when appropriate.
• Behavioral strategies: Cognitive behavioral therapy and pain coping skills can reduce pain impact.
• Anti-inflammatory habits: Regular exercise, sleep optimization, and a fiber-rich diet that supports bowel regularity may reduce symptom flares.

Hormone therapy after hysterectomy: special considerations for endometriosis

Estrogen therapy effectively treats hot flashes, bone loss, and genitourinary syndrome of menopause after ovary removal. However, in people with prior endometriosis, estrogen alone may activate residual implants. Many specialists consider using combined estrogen–progestin therapy or the lowest effective dose with close follow-up. Decisions should be individualized based on age, symptom severity, cardiovascular and bone health risks, and the extent of prior endometriosis.

When to seek care

• Pain that limits daily activities or does not improve
• New pelvic mass, persistent bloating, or early satiety
• Unexplained vaginal bleeding or post-coital spotting
• Fever, severe abdominal pain, vomiting, or signs of infection

Bring your operative report to visits if possible; it helps clarify what was removed and guides the evaluation.

The bottom line

After a total hysterectomy, true uterine fibroids do not grow back—but rare fibroid-like growths can develop, especially if tissue was morcellated or the cervix remains. Endometriosis can persist or recur because it lives outside the uterus. A structured evaluation can pinpoint the cause, and evidence-based treatments—from pelvic floor therapy to advanced hormonal options and minimally invasive surgery—offer meaningful relief. Partner with a gynecologist experienced in complex pelvic pain or endometriosis for an individualized plan.

Sources (selected)

• NIH MedlinePlus: Uterine Fibroids; Endometriosis; Hysterectomy
• Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD): Endometriosis overview
• FDA: Safety communications on laparoscopic power morcellation; Drug approvals for elagolix (endometriosis pain) and relugolix combination therapy
• American College of Obstetricians and Gynecologists (ACOG): Patient FAQs on Endometriosis and Hysterectomy
• NCBI Bookshelf (StatPearls): Endometriosis; Ovarian Remnant Syndrome
• GARD (Genetic and Rare Diseases Information Center, NIH/NCATS): Ovarian Remnant Syndrome